Nursing performance in COVID-19 and non-COVID-19 units: Implications for occupational health

Abstract Objective: to analyze the implications of the pandemic on the Nursing team’s occupational health according to its performance in COVID-19 and non-COVID-19 units. Method: a multicenter and mixed-methods study, with a sequential explanatory strategy. A total of 845 professionals took part in the first stage, answering an electronic form which contained sociodemographic and work-related variables, as well as about the pandemic and their health, in addition to the Self-Reporting Questionnaire. 19 professionals were interviewed in the second stage. The quantitative data were submitted to statistical analysis and the qualitative ones to thematic content analysis, with integration by connection. Results: the pandemic exerted impacts on the professionals’ health, both in the COVID-19 and non-COVID-19 areas. However, composition of the teams presented different characteristics between the areas, as well as the risk perceptions and the work demands. Conclusion: the professionals working in areas COVID-19 and non-COVID-19 areas are equally affected, although with different work exposure regarding the requirements at work in the COVID-19 units and the fear of contamination in non-COVID-19 units.


Selection criteria
In the "QUAN" stage, all the workers from the four institutions were invited by means of institutional email messages, with inclusion of those who answered the electronic form. A sample of these respondents was included in the "qual" stage selected from the statements written in the open question, providing contact to talk more about the subject matter. The professionals excluded were those that were away from their work functions during the data collection period and who refused to be interviewed.

Sample definition
The "QUAN" stage consisted of a sample of 845 participants from the Nursing team, selected by convenience, exceeding the minimum number (534) statistically estimated with the aid of the statistical PSS Health software (Power and Sample Size for Health Researchers) (27) , with a 96% confidence level and a 4% estimate of absolute error, assuming 33.7% prevalence (28) .
The "qual" stage sample was intentionally obtained among the 353 individuals who answered the open question and defined at 19 participants through data saturation.

Intentionality of the selection of interviewees occurred by
choosing the best informants, through identification the answers that revealed interest in discussing their work experiences during the pandemic.

Study variables
The sociodemographic data were collected through dichotomous categorical variables such as sex (female or male), race/skin color (white or brown/black/others), marital status (single/without a partner or married/ with a partner) and numerical variables such as number of children. The work-related data were categorical polytomous variables such as institution (HA, HB, HC or HD), work shift (day, night or no fixed turn/relief staff), dichotomous variables such as position (nurse or nursing technician/assistant), employment contract [Consolidation of Labor Laws (CLT-Consolidação das Leis do Trabalho)]/ statutory or temporary] and if they had another contract (yes or no). The numerical variables were "time working in the institution", "time working in the profession" and "time working in the unit" (in years).
MPD suspicion, as well as data on life and health habits related to the pandemic (has a chronic disease, practices physical activity, increased alcohol consumption, works in a unit devoted to infected patients, assisted infected patients, started using medication, had a medical leave, due to suspected or confirmed COVID-19, belongs to the risk group, lives with people who belong to the risk group) were obtained through dichotomous categorical variables (yes or no), in addition to the "time away" numerical variable (in days). A five-point Likert scale was used for the following variables: sleep quality (from poor: "1" to excellent: "5"), increased level of demand at work (from nothing changed: "1" to intensely changed: "5"), fear felt in the face of exposure to being contaminated at work (from not afraid: "1" to very much afraid: "5") and impact on physical health (from no impact: "1" to intense impact: "5").
The study considered the sectors that devoted their physical area and care process exclusively to patients infected by the coronavirus as "COVID-19 units". The other sectors were understood as "non-COVID-19 units", intended to care for other causes (such as outpatient services and hospitalizations of any specialties) and/or that were adapted to carry out eventual care of patients infected with the coronavirus, their permanence being temporary in the area (such as emergencies and areas for exams). The open question available in the electronic form, to freely discuss their experiences during care performance in the pandemic, was used to guide the development of semi-structured questions that comprised the interview script of the second stage, as well as the results of the previous analysis of the data from the first stage of the study. The interview script, prepared by the authors of the study, consisted of six questions that dealt with daily work in the pandemic, organization of teams and processes, perceived changes, exposure to risk and impact on health.

Data collection
Quantitative data collection was conducted by means of an electronic form (Google Forms), sent via institutional email, provided and authorized by the institutions. The

Data treatment and analysis
The "QUAN" stage data were entered into an Excel spreadsheet and analyzed in SPSS, version 20. The categorical variables were presented as absolute and relative frequencies and the continuous ones, as central tendency and dispersion measures. The Chi-Square or Fisher's Exact tests were employed for the association between the categorical variables, according to the cell's frequency. The Shapiro-Wilk normality test resulted in the identification of the asymmetric distribution of the continuous variables, which had their analysis performed using the non-parametric Mann-Whitney test in the comparison of the groups. "Works in a unit devoted to infected patients" was the dependent variable of this study, which was crossed with the independent ones.
The data with two-tailed "p"-values below 0.05, or with a 95% confidence interval, were considered as statistically significant differences.
In the "qual" stage, the data were transcribed and submitted to thematic content analysis (29) , permeating After the quantitative and qualitative analyses, a joint data analysis was performed, combined from the connection, so that the results could be integrated, improving and expanding understanding of the theme. Joint-display was used to allow for better data visualization (30) , favoring the emergence of new ideas (31) .

Results
The study first stage included 845 Nursing team However, regarding the experience of the care provided to infected patients, it was found that 575 (83.3%) had these experiences working in non-COVID-19 units. Table 1 shows the distribution of participants according to their sociodemographic and work-related characteristics according to the work unit in coping with the COVID-19 pandemic. Table 2    Regarding the MPD, there were no statistically significant differences between the COVID-19 and non-COVID-19 areas. Figure 1 illustrates the high prevalence of suspected MPD in the Nursing professionals from both teams.
Rev. Latino-Am. Enfermagem 2023;31:e3741. was evidenced about PPE availability and the constant changes in the care flows in order to maintain distancing of uncontaminated patients from the suspected cases, which was a generator of many uncertainties due to the care rules.  Rev. Latino-Am. Enfermagem 2023;31:e3741.

Discussion
Composition of the teams that worked in the COVID-19-and non-COVID-19 units revealed a number of differences, even with regard to sex. Although Nursing is a mostly and historically female profession, both in this study and in another one carried out during the pandemic, there was a significant number of male professionals comprising the teams of units devoted to the care of patients infected with COVID-19 (32) . This fact can be due to the role socially attributed to men in the culture, linked to virility and courage, which often consolidates denial of vulnerability and fear (33) . On the other hand,

Mixed result: The pandemic similarly impacted the health of Nursing workers working in COVID-19 non-COVID units
Starting to use medication during the pandemic (p=0.340), absence from work due to health reasons during the pandemic (p=0.218), absence from work due to suspected COVID-19 (p=0.351) and to COVID-19 diagnosis (p=0.221), self-assessment of the impact on physical health (p=0.597) and Minor Psychological Disorders (p=0.535) were also present among the workers who worked in COVID-19 and non-COVID-19 units.

COVID-19 Units
We witnessed scenes of anxiety and panic attacks in professionals, blackouts, paralysis and this will never

Non-COVID-19 units
The first patient I received that was positive made me feel afraid, that week I was very anxious, until 10 days I was very anxious.
Thinking that I ended up touching the patient, and not having the proper protection.
A study that disclosed greater severity in the This constant concern for the possibility of incorrect actions by colleagues possibly ends up burdening the work of the most experienced, as there was an increase in work demands in the COVID-19 units (10,42) also due to the rigor in PPE use, such as paramentation and de-paramentation and its prolonged use, as well as the change in the profile of the patients, who were distributed by specialties across the units, such as Oncology and Hematology, and had their particularities added to the coronavirus infection (10,43) .
The change in the patient profile was due to the need to create units devoted to the care of patients infected with the coronavirus, in order to control its dissemination.
However, in addition to also manifesting severe forms of the disease, becoming critical care patients (38) , people Another difficulty faced by the health services and that put Nursing professionals at risk was lack of PPE, which was a worldwide problem at the beginning of the pandemic, as well as the lack of training for its proper and prolonged use (43)(44) , which caused pressure injuries (45) . In Italy, nurses in COVID-19 units linked these situations to the large number of contamination cases in the professionals, requiring the development of several protocols such as training for the proper use of PPE (46) .
For the professionals who were not working directly with infected patients, lack of adequate protection and the uncertainty of the fact that a given patient was distancing and use of masks were respected (48) . During the pandemic, stigmatization and prejudice brought about concerns to Nursing professionals, who sometimes face problems regarding the family and social support network that can negatively affect their mental health (15,48) .
On the other hand, the professionals from COVID-19 units had the same feeling, but in relation to the colleagues of the institution who did not work directly with infected patients, when they shared changing rooms, corridors and elevators, even when they were no longer wearing contaminated uniforms. Both felt the need to isolate themselves from people in general life in order not to be held responsible for contaminating anybody The professionals who dealt directly with COVID-19 also distanced from colleagues from other sectors, both because of the prejudice suffered and because they were not considered contamination means within the institutions (43,49) .
There were no statistically significant differences ward (23) .
Among the possible explanations provided by the authors (23) , there is the fact that the professionals who Regarding the finding about the feeling of fear in the face of the contamination risk experienced with higher prevalence by the professionals from non-COVID-19 areas, it is worth relating this to the study (50) found more contaminated professionals in non-COVID-19 areas when compared to professionals from COVID-19 areas.
In addition to weighing the negative experience of the feeling of fear found in the current study, a number of authors (12,51) showed that the fear of being contaminated was a predictive factor for the development of depression among Nursing workers.
The studies developed with nurses showed higher levels of illness among those who work directly with infected patients (12,15,34,52) . In China (15) , they showed more severe degrees of depression, anxiety, insomnia and anguish; in Germany (12) they had more depression, exhaustion and stress, when compared with professionals from the non-COVID-19 units, as well as in Iran (34) , where exhaustion and stress prevailed in these professionals. In the current study there was no difference regarding the psychological health of the professionals from different areas.
Although this study did not identify differences between the performance units with regard to MPD, their high prevalence among the participants stands out, as well as in a study carried out during the pandemic in Brazil (53) with 490 professionals from a Nursing team, revealing that 30.4% of the participants had some mental disorder diagnosed, with moderately severe or severe anxiety as the most prevalent diagnosis, followed by moderately severe or severe depression. In Canada (54) , more than 50% of the participants in a study presented depression symptoms, with 42% moderate, serious or severe and more than 65% of the professionals had anxiety, with 22% serious or severe.
This study was developed entirely online, which may be one of the largest limitations to be considered, as the demands for remote interactions began to overwhelm the professionals in the pandemic, who often were not willing to stay in front of the computer or other digital medium for this reason, as well as the fact that the quality of the interviews was impacted by virtuality. The fact that the research was developed by nurses, who somehow also worked during the pandemic, facilitated the study logistics but generated negative emotions due to the impact of the pandemic on all life instances.
Another limitation was found in relation to time, a factor inherent to cross-sectional research, as it is a clipping of a given moment and resulting from the